SUMMARY AND CONCLUSIONS

“Learn the past, watch the present, and create the future.”

In October 2009, Don Berwick and I were out of the country when we received invitations from Susan Hassmiller to co-author a background paper on the future of nursing education for the Robert Wood Johnson Foundation/Institute of Medicine (RWJF/IOM) Committee on the Future of Nursing. Initial conversations led to long lists of potential topics to be covered. Inevitably, we kept coming back to the question: What would be useful to committee members who deserved a base for their deliberations that was focused and helpful? In the end, we decided that detailed descriptions of the current challenges and recommendations for the future of nursing education from two people were not the answer. Instead, we requested and received permission to challenge five leaders, in addition to ourselves, to write short papers focused on recommendations addressing the most important three issues from each of their perspectives.

With input from the RWJF/IOM Committee members and staff, we chose five esteemed (and busy) leaders and asked them to rise to this challenge within 10 weeks. Each person agreed, and each met the deadline. There were no group discussions, and, since each of us submitted our papers at the same time (no one finished early!), no one altered his or her content based on reading someone else’s contributions.

1

The responsibility for the content of this article rests with the authors and does not necessarily represent the views of the Institute of Medicine or its committees and convening bodies.

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I
The Future of Nursing Education1
Edited by Linda R. Cronenwett, Ph.D, R.N., FAAN
University of North Carolina at Chapel Hill School of Nursing
SUMMARY AND CONCLUSIONS
“Learn the past, watch the present, and create the future.”
In October 2009, Don Berwick and I were out of the country when we re-
ceived invitations from Susan Hassmiller to co-author a background paper on the
future of nursing education for the Robert Wood Johnson Foundation/Institute of
Medicine (RWJF/IOM) Committee on the Future of Nursing. Initial conversa-
tions led to long lists of potential topics to be covered. Inevitably, we kept coming
back to the question: What would be useful to committee members who deserved
a base for their deliberations that was focused and helpful? In the end, we decided
that detailed descriptions of the current challenges and recommendations for the
future of nursing education from two people were not the answer. Instead, we
requested and received permission to challenge five leaders, in addition to our-
selves, to write short papers focused on recommendations addressing the most
important three issues from each of their perspectives.
With input from the RWJF/IOM Committee members and staff, we chose
five esteemed (and busy) leaders and asked them to rise to this challenge within
10 weeks. Each person agreed, and each met the deadline. There were no group
discussions, and, since each of us submitted our papers at the same time (no one
finished early!), no one altered his or her content based on reading someone else’s
contributions.
1 The responsibility for the content of this article rests with the authors and does not necessarily
represent the views of the Institute of Medicine or its committees and convening bodies.
4

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4 THE FUTURE OF NURSING
The seven papers are reprinted below, followed by a summary of the themes
that emerged across papers. How does it match what you would have written?
SUMMARY
The authors of the preceding papers came from the Northeast, South, Mid-
west, and Western parts of the country. One is a distinguished physician col-
league, and the nursing educators are comprised of three professors (one a dean
emeritus) and three current deans. Each has exerted leadership—in science,
teaching, practice, and policy—for multiple decades. Each leads initiatives that
extend beyond the boundaries of their places of employment. One is the current
president of the American Academy of Nursing. What can we learn across the
issues each chose to raise?
The style of the papers differed, so what was called a recommendation, con-
clusion, or issue varies. I extracted each major point, regardless of label. These
major points from all authors are included in the categories below. Following
each theme, authors for whom this was a major point are listed in regular font.
Some additional authors mentioned the same point but not at the level of recom-
mendations, conclusions, or major issues, and their names are listed in italics.
Finally, I organized themes using categories that the RWJF/IOM committee chose
for panel presentations at their upcoming meeting (what to teach, how to teach,
where to teach), adding a few remaining categories so that all major points were
included.
What to Teach (or What Students Should Learn)
• Competencies necessary for continuous improvement of the quality and
safety of health care systems—patient-centered care, teamwork and col-
laboration, evidence-based practice, quality improvement, safety, and
informatics (Berwick, Cronenwett, Tanner)
− Mastery of knowledge of systems, interpretations of variation, human
psychology in complex systems, and approaches to gaining knowl-
edge in real-world, local contexts (Berwick)
− Skills and methods for leadership and management of continual im -
provement, for nurse-teachers and nurse-executives (Berwick)
• Competencies needed in new care delivery models
− Population health and population-based care management (Tanner)
− Care coordination (Tilden)
• Knowledge based on standardized science prerequisites (Dracup,
Tanner)
• Health policy knowledge, skills, and attitudes (Tilden)
• C ompetencies related to emerging health needs—e.g., geriatrics
(Tanner)

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4
APPENDIX I
How to Teach
• Guide students in integrating knowledge from clinical, social, and be -
havioral sciences with the practice of nursing to enhance development
of clinical reasoning skills (Cronenwett, Dracup, Tanner, Tilden)
• Enhance opportunities for interprofessional education (Cronenwett,
Dracup, Gilliss, Tilden, Tanner)
− Evaluate and test models of interprofessional education, including
timing, determination of what levels of students should learn together,
and what content is most effectively delivered with interprofessional
learners (Tilden)
• Develop and test new approaches to pre-licensure clinical education,
including use of simulation (Dracup, Tanner)
• Involve students in interprofessional quality improvement projects
(Berwick, Gilliss, Cronenwett)
• Develop model pre-licensure curricula that incorporate best practices in
teaching and learning and can be used as a framework for community
college–university partnerships (Tanner)
Where to Teach
• In baccalaureate and higher degree programs (Aiken, Cronenwett,
Dracup, Gilliss, Tanner, Tilden)
− Significantly increase the number and proportion of new registered
nurses who graduate from basic pre-licensure education with a bac-
calaureate or higher degree in nursing (Aiken, Cronenwett)
− Require the BSN for entry into practice (Dracup, Tilden)
− Support community college/university partnerships that increase the
number of associate degree graduates that complete the baccalaureate
degree (Dracup, Tanner)
− A llow community colleges to provide baccalaureate degrees
(Dracup)
• In post-graduate residency programs
− Develop and test clinical education models that include post-graduate
residency programs (Tanner)
− Implement requirement of post-graduate residency for initial re-
licensure (Cronenwett, Tanner)
• In health care settings that foster day-to-day change and improvement
(Berwick)
• In programs built on strong academic–practice setting partnerships
(Cronenwett, Gilliss)
− At Academic Health Centers, promote governance structures that
combine the strategic, rather than operational, oversight for nursing
(Gilliss)

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40 THE FUTURE OF NURSING
• In settings that are models of integrated care where care coordination
skills can be developed (Tilden)
Who Teaches (Characteristics of Desired Faculty Members of the Future)
Increase the number of faculty members:
• Whose criteria for appointment and advancement include recognition of
practice-based accomplishments, including engagement in the work of
improving health care (Berwick, Gilliss, Dracup, Cronenwett)
• Who can move easily during careers between practice and academe
(Gilliss)
• Who shorten their career paths from BSN to doctoral degree (Aiken,
Dracup)
• Who maintain professional certification and/or clinical competence
(Gilliss)
• Who build alliances with faculty in other disciplines (medicine, engi-
neering, business, public health, law) (Gilliss)
• Who are capable of leading efforts to advance interprofessional educa-
tion (Dracup, Tilden)
Recommendations: To Nursing Organizations
• Ensure that schools produce ever-increasing numbers of nurse practi-
tioners for primary care roles at a time when expanded access to health
care will increase society’s need for primary care providers (Cronenwett,
Gilliss)
− Challenge current credit-heavy requirements and test teaching in-
novations that improve competence while reducing program credits
(Gilliss)
• Support the faculty development necessary to bring about the magnitude
of reforms in nursing education recommended in the Carnegie study,
necessitated by advances in nursing science and practice and guided by
advances in the science of learning (Tanner)
• Advance post-master’s DNP education, maintaining specialist prepara-
tion at the master’s program level (Cronenwett, Gilliss)
− Fund initiative to facilitate professional consensus that DNP programs
should be launched as post-master’s program for the foreseeable fu-
ture (Cronenwett)
− Clarify the expectations for nurse scientists interested in translational
research—will both the DNP and the PhD be required? Will the DNP
alone be sufficient for tenure-track positions in research-intensive
universities? (Dracup)

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41
APPENDIX I
• Include as accreditation criteria for nursing education programs:
− Substantive nursing education–service partnerships, e.g., in shared
teaching and clinical problem solving (Cronenwett, Gilliss)
− Interprofessional education (Cronenwett, Dracup, Gilliss, Tilden)
− Development of competencies in health policy (Tilden)
− Student/faculty participation in or leadership of teams that work to
improve health care (Berwick, Cronenwett)
− Student competency development related to health policy (Tilden)
• Identify top ten areas of needed faculty development and provide public
recognition for success (Gilliss)
• Support a learning collaborative of state boards of nursing willing to
implement regulatory requirements for transition to practice residency
programs as a prerequisite for initial re-licensure (Cronenwett)
• Require proof of a nurse’s participation in or leadership of teams that
work to continuously improve the health care system for renewal of
certification (Berwick)
• Urge testing of interprofessional teamwork and collaboration and health
policy competencies in licensure exams (Tilden)
Recommendations: To Government and Other Organizations
• Increase scholarships, loan forgiveness, and institutional capacity
awards to increase the number and proportion of newly licensed nurses
graduating from baccalaureate and higher degree programs (Aiken,
Cronenwett)
• Increase scholarships, loan forgiveness, and institutional capacity awards
for graduate nurse education at master’s and doctoral levels (Aiken,
Dracup)
• Redirect Medicare GME nursing education funds to support graduate
nurse education (Aiken, Dracup, Tanner)
• Redirect Medicare GME nursing education funds from hospital-based
pre-licensure programs to postgraduate residency programs (Cronenwett,
Tanner)
• Promote innovation and evaluation of novel approaches to improving
preparation for the practice of nursing through expanded Title VIII fund-
ing (Cronenwett, Tanner)
• Invest in nursing education research, related particularly to the evalua -
tion of multiple pathways to licensure (Tanner)
• Use CTSA or other research facilitation structures to promote knowledge
development at the point of care, translation of knowledge into prac-
tice, practice improvements, and interprofessional education (Dracup,
Gilliss)

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42 THE FUTURE OF NURSING
• Create a federal health professions workforce planning and policy capac-
ity in the Executive Branch (Aiken)
• Expand authorities for Title VII/VIII funds to support development and
evaluation of interprofessional education innovations (Gilliss)
• Expand Nurse Faculty Loan Programs and other loan forgiveness/
scholarship programs that produce more faculty (Aiken, Dracup)
• Encourage public and private resource investments that incentivize stu-
dents and nursing programs to expedite production of qualified nurse
faculty by shortening the trajectory from entry into basic nursing pro-
grams through doctoral and post-doctoral study (Aiken, Dracup)
• Use Perkins funds to incentivize community college nursing programs
to increase the proportion of their nursing students who complete their
initial education with a BSN (Aiken)
• Increase programs that support greater production of nurse practitioners
for primary care (and remove legal barriers to interprofessional educa-
tion and practice) (Aiken, Cronenwett)
• Fund a longitudinal study to track state-based data on number and
proportion of new nurse graduates from ADN vs. BSN/higher degree
programs (Cronenwett)
− Advance media attention to states that exemplify “best practices” in
the distribution of new nurse graduates from ADN vs. BSN programs
(Cronenwett)
• Include health services research (in addition to drug and treatment in -
tervention trials) in initiatives to enhance comparative effectiveness
research (Aiken)
• Require universities and colleges (presidents, provosts, deans) to support
infrastructures and mandates for interprofessional education (Tilden)
CONCLUSION
The recommendations of seven leaders committed to the development of
future generations of health professionals included some expected diversity of
views. Nonetheless, given the long list of issues that would have been covered
had we chosen to write one comprehensive paper, a remarkably small number of
themes emerged. Hopefully, these rich ideas and themes can be used to inform the
deliberations of the RWJF/IOM Committee on the Future of Nursing. Even more
hopefully, a collective national response to these important issues will create a
future that meets nursing’s obligations to the society it serves.

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43
APPENDIX I
NURSING EDUCATION POLICY PRIORITIES
Linda H. Aiken, Ph.D., FAAN, FRCN, R.N.
University of Pennsylvania
Nursing is one of the most versatile occupations within the health care
workforce. In the 150 some years since Nightingale developed and promoted
the concept of an educated workforce of caregivers for the sick, modern nursing
has reinvented itself a number of times as health care has advanced and changed
(Lynaugh, 2008). As a result of nursing’s versatility, new career pathways for
nurses have evolved attracting a larger and more diverse applicant pool and a
broader scope of practice and responsibilities. Nursing, because of its versatil-
ity, has been an enabling force for change in health care along many dimensions
including but not limited to the evolution of the high-technology hospital, the pos-
sibility for physicians to combine office and hospital practice, length of hospital
stay among the shortest in the world, reductions in the work hours of resident
physicians to improve patient safety, extending national primary care capacity,
improving access to care for the poor and rural residents, and contributing to
much needed care coordination for the chronically ill and frail (Aiken et al.,
2009). Indeed, with every passing decade, nursing has become a more integral
part of health care services to the extent that a future without large numbers of
nurses is impossible to envision.
A POLICY CHALLENGE
From a policy perspective, nursing’s versatility is important to note for the
simple reason that nursing has evolved faster than public policies affecting the
profession. The result is that nursing’s forward progress to better serve the public
is hampered by the constraints of outdated public policies involving govern-
ment education subsidies, workforce priorities, scope of practice limitations and
regulations, and payment policies. An important priority in national health care
reform is achieving better value for the expenditures made on health services.
Since health care is labor intensive, getting more value will depend in large part
on enhancing productivity and effectiveness of the workforce. Nurses represent
a large and unexploited opportunity to achieve greater value.
The purpose of this paper is to identify and discuss several key changes in
nursing education policy that are critically needed to shape the nurse workforce
to best serve the health care needs of the American public in the years ahead. It
is written with the assumption that nurse scope of practice and payment policy
reforms will take place over the near term to remove some of the existing barri-
ers to nurses practicing to the full extent of their education and expertise. This
assumption is based on steady progress in removing barriers to nursing practice
at the state level and language in current national health reform legislation show-

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44 THE FUTURE OF NURSING
ing greater neutrality in the designation of types of health professionals who can
participate in and lead new initiatives in primary care and chronic care coordina-
tion. Changes in nursing education policies are needed to ensure that the nurse
workforce of the future is appropriately educated for anticipated role expansions
and changing population needs.
Five priority recommendations regarding the future of nursing education are
advanced for consideration by the RWJF Committee on the Future of Nursing
at the IOM:
• Increase and target new federal and state subsidies in the form of schol-
arships, loan forgiveness, and institutional capacity awards to signifi-
cantly increase the number and proportion of new registered nurses
who graduate from basic pre-licensure education with a baccalaureate
or higher degree in nursing.
• Increase federal and state subsidies for graduate nurse education at the
master’s and doctoral levels in the form of scholarships, loan forgive-
ness, and institutional capacity with a priority on producing more nurse
faculty.
• Encourage public and private resource investments to incentivize students
and nursing programs to expedite production of qualified nurse faculty by
shortening the trajectory from entry into basic nursing education through
doctoral and post-doctoral study by expedited bachelor of science in
nursing (BSN) to PhD programs and comparable innovations.
• Create a federal health professions workforce planning and policy capac-
ity in the Executive Branch with authority to recommend to the President
and the Congress health workforce policy priorities across federal agen-
cies and departments.
• Recommend the inclusion of health services research on various forms of
nursing investments in improving care outcomes including comparisons
of the cost effectiveness of improving hospital nurse-to-patient ratios,
increasing nurse education, and improving the nurse work environment.
At present comparative effectiveness research is more focused on drug
and treatment intervention trials than on innovations in care delivery
including workforce interventions.
PRIORITY FUNDING TO INCREASE INITIAL BSN GRADUATES
Every year the percent of new registered nurses graduating from associate
degree programs increases, and it is now over 66 percent of all new nurse gradu-
ates. Multiple blue ribbon panels on nursing education, including the just released
Carnegie Foundation Report on Nursing Education (Benner et al., 2010) as well
as health workforce reports to Congress for two decades, have concluded that
there is a substantial shortage of nurses with BSN and higher education to meet

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4
APPENDIX I
current and future national health care needs. Advances in medical science and
technology, the changing practice boundaries between medicine and nursing, and
the increase in the share of the population with multiple chronic health conditions
create a level of complexity in health care that requires a more educated health care
workforce. Nursing is the least well educated health profession by far but the one
experiencing the greatest expansion in scope of practice and responsibilities. The
National Advisory Council on Nurse Education and Practice (NACNEP) (1996),
policy advisors to the Congress and the U.S. Secretary of Health and Human
Services on nursing issues, urged almost 15 years ago that policy actions be taken
to ensure that at least 66 percent of nurses would hold a baccalaureate or higher
in nursing by 2010; the actual result is closer to 45 percent. As described in the
sections below, growing evidence suggests that the shortage of nurses with BSN
and higher education is adversely affecting a number of dimensions of health care
delivery now and these problems will only become exaggerated in the future.
Quality of Hospital Care
A growing body of research documents that hospitals with a larger propor-
tion of bedside care nurses with BSNs or higher qualifications is associated with
lower risk of patient mortality. Aiken and colleagues (2003) in a paper published
in the Journal of the American Medical Association (JAMA) showed that in 1999,
each 10 percent increase in the proportion of a hospital’s bedside nurse workforce
with BSN qualification was associated with a 5 percent decline in mortality fol-
lowing common surgical procedures. A similar finding was published by Friese
and associates for cancer surgical outcomes (Friese et al., 2008). Aiken’s team
has replicated this finding in a larger study of hospitals in 2006. Similar results
have been published for medical as well as surgical patients in at least three large
studies in Canada and Belgium (Estabrooks et al., 2005; Tourangeau et al., 2007;
Van den Heede et al., 2009).
This research has motivated the American Association of Nurse Executives,
the major professional organization representing hospital nurse chief executive
officers who employ 56 percent of the nation’s nurses, to establish the BSN as
the desired credential for nurses. Many hospitals, particularly teaching hospitals
and children’s hospitals, are acting on the evidence base by requiring the BSN
for employment. Nurse executives in teaching hospitals have a goal of 90 percent
BSN nurses, and community hospital nurse executives aim for at least 50 percent
BSN-prepared nurses (Goode et al., 2001). Since only 45 percent of bedside care
nurses have a BSN, many executives cannot reach their goals.
Access and Costs
There is some research evidence that the cost effectiveness of nursing im-
proves with a more educated workforce. In Aiken’s JAMA paper, evidence was

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4 THE FUTURE OF NURSING
presented to show that the mortality rates were the same for hospitals in which
nurses cared for 8 patients each, on average, and 60 percent had a BSN and for
hospitals in which nurses cared for only 4 patients each but only 20 percent had
a BSN (Aiken, 2008; Aiken et al., 2003). More research is needed to assess the
comparative value of investing in different nursing strategies that evaluate the
relative cost and outcomes of increasing nurse staffing, educational levels, and
improving the organizational context and culture of the nurse work environment.
At this point the evidence is encouraging that a more educated hospital nurse
workforce might allow for a smaller nurse workforce without adversely affect-
ing patient outcomes. If confirmed in future research, this finding could have
important implications for both cost of hospital care and for the number of nurses
actually needed in the future to staff hospitals.
In the ambulatory sector, there is a strong research base documenting that
nurses with advanced clinical training, usually master’s degrees in advanced
clinical practice, provide primary care with outcomes comparable to, and in some
domains like symptom control and satisfaction better than, those of physicians
and with lower costs (Griffiths et al., 2010; Horrocks et al., 2002). Rand research-
ers estimated, for example, that the state of Massachusetts could save up to $8
billion over a decade by attracting more advanced practice nurses and removing
barriers that prevent them from practicing at the full level of their education and
expertise (Eibner et al., 2009). Increased use of advanced practice nurses is one
of the very few practice innovations currently underconsidered in national health
reform, including medical homes and chronic care coordination, that would yield
net cost savings nationally according to Rand researchers (Hussey et al., 2009).
How the Shortage of BSN Nurses Impacts Future Nurse Supply
As argued above, the shortage of BSN nurses has implications for health care
quality and safety, access, and costs of care. A less well recognized consequence
of the shortage of BSN nurses is a shortage of faculty which could have a long-
term impact on national production capacity of nurses for the future.
The Department of Labor estimates that 600,000 new jobs will be created
for nurses over the next 10 years, the highest rate of new job production for any
profession (Bureau of Labor Statistics, 2009). In addition, over a half million
nurses in the current workforce, which has an average age of around 48, will
reach retirement age over the same period, resulting in the need for over a mil-
lion nurses to be added to the national workforce. The good news is that there is
tremendous interest in nursing as a career in the United States after a century of
difficulty attracting the best and brightest to nursing. The reasons for this unprec-
edented interest are multifaceted, having to do with attractive incomes, averaging
nationally $65,000 a year and higher in some locations, better job prospects than
in other employment sectors, and perceptions of personally satisfying work help-
ing others. If we can take advantage of this unprecedented interest and expand
nursing school production, future nursing shortages could be greatly attenuated.

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4
APPENDIX I
The bad news is that nursing schools do not have the capacity to absorb
the great windfall in applicants. Estimates suggest that at least 40,000 qualified
applicants to nursing schools are being turned away each year (AACN, 2009).
There are several reasons why nursing schools are unable to accept the influx of
applicants. Nursing schools have expanded enrollments steadily for more than
a decade with graduations increasing from about 75,000 in 1994 to 110,000 in
2008. Resources of all kinds are now stretched and schools are having difficulty
expanding further. Institutions of higher education in general are experiencing
serious budget constraints and as a result are slowing enrollment growth. Addi-
tionally the shortage of nursing faculty has become a major constraining factor.
A strategy for ameliorating the nurse faculty shortage that has received
little attention to date is to increase entry-level education of nurses to produce
a larger pool of nurses likely to obtain graduate education. In a recent paper in
Health Affairs Aiken and colleagues provided a cohort analysis to determine
the highest education achieved by nurses receiving their basic or initial nursing
education between 1974 and 1994 (Aiken et al., 2009). We found that choice of
initial nursing education program—associate degree or baccalaureate—was the
major predictor of final educational attainment. Close to 20 percent of nurses ir-
respective of initial nursing education obtain a higher degree. However, of the 20
percent of associate degree nurses who obtain an additional degree, 80 percent
stop at the baccalaureate degree. Of the 20 percent of nurses with a baccalaureate
degree who go on for additional education, almost 100 percent obtain at least a
master’s degree. This is an important finding for the design of policy interventions
since investments in encouraging BSN education have not distinguished between
RN-to-BSN programs and basic BSN programs. The yield for teachers is entirely
different between the two types of programs. If the current scenario of distribu-
tion of nurses by type of basic education had been reversed since 1974 and 66
percent of nurses had graduated from BSN programs instead of 33 percent, we
estimate that there would be over 50,000 more nurses with master’s and higher
degrees today.
We concluded in our Health Affairs paper that it was a mathematical im-
probability that the nurse faculty shortage could be solved without changing the
distribution of nurses by type of basic education. There are simply not enough
nurses who obtain a master’s or higher degree to meet the dramatic increase in
demand for clinicians, administrators, teachers, and leaders who require a gradu-
ate degree.
What would be the expected yield in terms of nursing faculty that would be
likely to obtain by increasing basic BSN education? To answer this we undertook
an analysis of the National Sample Surveys of Registered Nurses over time to ex-
plore whether career trajectories of nurses with graduate education had changed
over time. The answer is yes—significantly. For example, in 1982, 17 percent
of nurses with master’s degrees and 62 percent of nurses with doctorates were
in faculty positions compared to only 7 percent of master’s and 41 percent of
nurses with PhDs in 2004. Nurses with graduate degrees are selecting positions in

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4 THE FUTURE OF NURSING
students’ greater familiarity with each others’ roles, competencies, nomenclatures,
and scopes of practice will result in more collaborative graduates. Graduates from
programs with IPE training will be ready to work effectively in patient-centered
teams where miscommunication and undermining behaviors are minimized or
eliminated, resulting in safer, more effective care and greater clinician and patient
satisfaction. Specifically, IPE is thought to achieve collaboration in implementing
policies and improving services, prepare students to solve problems that exceed
the capacity of any one profession, improve future job satisfaction, create a more
flexible workforce, modify negative attitudes and perceptions, and remedy fail-
ures in trust and communication (Barr, 2002).
Efforts have been made to evaluate the effectiveness of IPE in improving
outcomes, typically including increased student satisfaction, modified negative
stereotypes of other disciplines, increased collaborative behavior, and improved
patient outcomes. However, IPE’s effect is not easily verified since control group
designs are expensive, reliable measures are few, and time lapses can be long
between IPE and the behaviors of graduates. Barr and colleagues reviewed 107
evaluations of IPE in published reports, judged to be of sufficient quality for in-
clusion according to Cochrane review standards (www.cochrane.org), and found
support for three outcomes: IPE creates positive interaction among students and
faculty; encourages collaboration between professions; and improves aspects of
patient care, such as more targeted health promotion advice, higher immunization
rates, and reduced blood pressure for patients with chronic heart disease (Barr
et al., 2005). In further work, Reeves et al. (2009) reviewed six later studies that
met methodology inclusion criteria as randomized controlled trials, controlled
before-and-after studies, and interrupted time series design studies. Four of the
studies found that IPE improved aspects of how clinicians worked together, such
as an improved working culture and decreased errors in an emergency depart-
ment, improved care management for domestic violence victims, and improved
knowledge and skills of clinicians caring for mental health patients. The remain-
ing two studies found that IPE had no effect at all. Although empirical evidence
is mixed, there is widespread theoretical agreement and anecdotal evidence that
students who demonstrate teamwork skills in the simulation lab or at the bed- or
chair-side with patients will apply them beyond the walls of their academic pro-
grams, particularly if valued and reinforced by the care environments in which
they later work.
In the early days of IPE, students graduated into patient care environments in
which siloed and hierarchical systems predominated, thus creating a significant
disconnect between their college-based learning and post-graduation experi-
ence. Now, 10 years into the widespread reforms triggered by the IOM’s searing
Quality Chasm reports, the practice environments students enter tend to reinforce
rather than discourage cooperative behaviors and attitudes. This shift suggests
a readiness for IPE and fuels the momentum among health science universities
toward a growing acceptance of IPE in curricula.

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APPENDIX I
IPE goes well beyond classroom-type courses comprised largely of didactic
lectures, considered ineffective in cultivating team-based behaviors. Sitting side-
by-side in lecture halls produces little student engagement with either the faculty
or other students. From a pedagogical perspective, IPE learning comes from
conjoint reflection, problem solving, and experience. Effective IPE training pro-
duces much more than the sum of its parts, rather, it generates interprofessional
discourse that shapes collaborative thinking and behavior. IPE typically takes
one or more of three approaches: (1) clinical skills lab simulation activities using
manikins or standardized patients in case scenarios often videotaped to facilitate
review and reflection, (2) service learning projects that enhance students’ civic
engagement often with diverse communities, and (3) specific patient group clinics
such as in the care of geriatric or HIV/AIDS patients.
Barriers to IPE exist (Gilbert, 2005) but are surmountable. Jurisdictions of
faculty and professional organizations abound. Different accrediting bodies are
loath to yield control over traditional curricula and standards. Space in curricula,
with their emphasis on factual content over synthesis, integration, and coopera-
tion, is limited. Relatively rigid academic calendars control course schedules.
Other barriers pertain to motivating faculty. How to reward and give faculty credit
for IPE when the traditional reward systems such as promotion, tenure, and merit
raises are governed within, not across, professions. Resources of the various
deans to support IPE likely differ. Typically schools of nursing have smaller over-
all budgets than schools of medicine but a higher percent of funding that supports
the education mission. Medical school faculty typically are expected to generate a
larger proportion of their salaries through clinical practice and/or research. When
done well IPE can be expensive for many reasons, e.g., small groups with stability
over time to allow for reflection and the development of trust, and/or expensive
equipment for simulations. These budgetary issues can contribute to different
levels of willingness of deans to support IPE.
Recommendations
1. Students at all levels of nursing education—baccalaureate, master’s, and
doctoral—must have exposure to IPE training and demonstrate competence
in interprofessional collaboration.
2. Since academic curricula tend to resist change unless pressured by external
forces such as accreditation requirements and licensure/certifying exam con-
tent, major education and standard-setting organizations must cooperate to
bring about IPE. In addition, endorsement of IPE must come from the highest
levels within academic settings, including presidents, provosts, and deans.
3. Nursing faculty need development in IPE teaching, which requires structure
and funding. The traditional notion of “teacher as expert” urgently needs
replacement with teacher as coach and facilitator. Faculty, whose average
age nationally is in the mid-50s, need the tools to make this transition. In

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addition, since most nursing faculty are not active in practice, their own
clinical experience is often dated and sometimes based on past unsatisfying
interprofessional relationships, making them poor champions for IPE.
4. The level and timing of bringing various students together requires analysis
and pilot testing because of students’ varying educational pathways and
readiness for IPE. For example, evaluate pairing senior medical students with
graduate nursing and allied health students, in an effort to have students bring
relatively comparable amounts of university education and clinical exposure
to the experiences.
5. IPE should be structured around knowledge, skills, and competencies to in -
clude: interpersonal and listening skills; techniques for constructive dialogue
and disagreements; how “evidence” in evidence-based practice is weighted;
systems thinking and problem solving; engaging patients and families as
active participants in care; verbal and nonverbal communication within the
care team; effective data reports and displays; stereotypes and prejudices;
and appreciating alternative conceptual frameworks and points of view.
EDUCATION IN CARE COORDINATION
Both the health professions literature and the popular press note that fail-
ures in patient care coordination are widespread in the United States. Indeed,
fragmented care, lost records, hand-offs without full information, poor return of
information from specialty care after referral, unnecessary and redundant proce-
dures and services—and the attendant patient fatigue, frustration, and costs—are
the very heart of the quality chasm. This problem is particularly acute for the 125
million people with chronic illness, disability, or functional limitations, and for
the elderly whose numbers will swell in the decades ahead. Short hospital stays
have exacerbated the problem.
Historically, primary care physicians coordinated their own patients’ care
within and across settings, but this function has all but been lost for myriad
reasons, including the growth in hospitalist care, patient self-referrals to special-
ists, the breakdown in communication between primary care and specialty care,
financing constraints on physician time, and overall uncoordinated systems of in-
formation technology. Failures in care coordination also can be traced to curricula
where the competencies required are assumed to be intuitive and thus minimized
or overlooked altogether.
Serious consequences result from poor care coordination. Especially wor-
risome is the post-hospital fate of patients. One study of care transitions found
that 19 percent of patients experienced adverse events following discharge from
a U.S. teaching hospital, most of which were avoidable and typically related to
poor communication (Forster et al., 2003). In another survey, 48 percent of newly
discharged patients reported not receiving information about side effects of new
prescriptions ordered at discharge (Schoen et al., 2005). In a study of urgent care

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APPENDIX I
patients, in 33 percent of cases information such as medical history and labora -
tory results was absent. In half the cases, the information was essential to patient
care (Gandhi, 2005).
As defined by the National Quality Forum (2006), care coordination should
meet patients’ needs and preferences for information and services across settings
over time. This facilitates beneficial, efficient, safe, and high-quality patient ex-
periences and improved health care outcomes. Qualities and principles of care
coordination include an enduring patient relationship and an established and
up-to-date care plan that anticipates routine needs, manages acute, episodic,
and chronic care needs and tracks progress toward goals that are jointly set by the
health care team and the patient/family. Care coordination ensures information
flow to and from referrals to specialty care or community services; ensures that
all team members, including the patient, are apprised of tests and services with
results readily available; reconciles medication orders and educates patients and
families about side effects and medication management; and reduces opportuni-
ties for error. Care coordination requires linguistically and culturally competent
communication with the patient and family, and seeks and responds to patient/
family questions and feedback.
Yawning gaps in care coordination are rallying many health professions or-
ganizations to search for solutions. For example, the American Board of Internal
Medicine Foundation structured its annual Forum on this topic in 2007, and later
spearheaded a consortium, referred to as the SUTTP Alliance (Stepping Up to
the Plate for Managing Transitions in Care) comprised of 10 medical specialty
societies, including the American College of Physicians, the American Academy
of Family Physicians, and the Society of Hospital Medicine. Nurses are the logi-
cal and ideal clinicians to fill the role of care coordinator, yet a similar alliance
among nursing organizations is absent. Germane to this paper, curricula in care
coordination in nursing education are underdeveloped.
Nursing research has produced important findings about advance practice
nurses as care coordinators. Brooten’s early work on care of low-birth-weight
infants (Brooten et al., 1986) showed significant cost and quality improvement
for early discharge and follow up home care by advance practice nurses (APNs).
Naylor and colleague’s (1999, 2004) studies of a transitional care model by
APNs for older cardiac patients post-hospitalization also demonstrated positive
effects of nurse-managed transitional care. In these models, APNs tailored post-
discharge services to each patient’s situation and followed patients by telephone
and home visits. The intervention emphasized patients’ and caregivers’ goals,
individualized plans of care developed and implemented in collaboration with
patients’ physicians, educational and behavioral strategies to address needs,
and coordination and continuity of care across settings. Overall outcomes were
positive across a series of studies, showing lower rehospitalization rates, fewer
hospital days when readmitted, substantial cost savings, and greater patient
satisfaction with care.

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Another superlative example of care coordination is On Lok Senior Health
Services for older adults living in San Francisco. For over 30 years, On Lok
has used multidisciplinary teams, electronic medical records, capitated pay-
ment, and a full range of services (including transportation, housing, meals,
adult day health services, and geriatric aides who make frequent home visits) to
provide seamless transitions for nursing home-eligible frail elders at lower cost
than usual care. On Lok became the model for similar institutions around the
Unitd States through the Program of All-Inclusive Care for the Elderly (PACE)
(Bodenheimer, 1999).
Another care coordination model is Tom Bodenheimer’s “teamlet”
(Bodenheimer and Laing, 2007), dyads that are a subset of the larger health
care team and comprised of a physician and, ideally, an experienced nurse or an
APN. Patients enter “an expanded encounter,” in which pre-, post-, and between-
visit care is continually monitored and coordinated by the nurse. Ingredients for
success include making sure the patient understands advice and direction and
agrees with the plan of care; communicating and interpreting laboratory and
other diagnostic tests, and continually looping information between the patient
and family, the physician, other care providers such as clinical pharmacists
and allied health. Bodenheimer notes that ideally the coach would be an RN or
an advanced practice nurse, but in their absence, a medical assistant could be
trained for the role.
Thus, the role of care coordinator as patient advocate, communicator, as-
sessor, and intervener, ideally suited to what nurses do best, presents a huge
opportunity for nursing education. But, as implied by Bodenheimer, the nursing
profession will be bypassed if nurses fail to seize the opportunity. To do so, how-
ever, requires that nursing school curricula incorporate not just the knowledge
underlying the competencies of the role but convey the importance of the role to
students by threading the concept and competencies of care coordination through-
out the curricula. As already mentioned, most nursing curricula currently teach
compartmentally, not across systems. Courses, particularly in the baccalaureate
program where attitudes about nursing and nursing care are first formed, focus
on content and skills in specific discrete clinical settings. Faculty generally teach
within, not across, settings of care. Often the master’s level Clinical Nurse Spe-
cialist program is the only track with a course or parts of courses that address
care transitions and care coordination, and this content may be confused with case
management, the latter being a more limited concept usually applied to contain-
ing costs within reimbursement systems.
Interprofessional education discussed above will by itself, improve gradu-
ates’ competence in care coordination because many of the competencies students
learn in IPE are relevant. However, there is a body of knowledge and sets of skills,
attitudes, and role-related behaviors specific to care coordination that should be
integrated throughout the levels of nursing education rather than confined to
episodic IPE training.

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APPENDIX I
Recommendations
1. BSN students should be placed for clinical training in new models of inte -
grated care that require care coordination, such as accountable care organiza-
tions within universities or medical homes.
2. MSN students should study the research cited above that shows the effective-
ness of APN transitional care. Components of MSN clinical training should
include the care coordination role.
3. Across education levels of nursing education, care coordination should be
structured around knowledge, skills and competencies to include: advanced
assessment skills appropriate for senior baccalaureate and master’s/DNP
students; interpersonal and communication skills necessary for the ability
to communicate with patients and families with a high degree of sensitiv-
ity and cultural competence, as well as the science-based skills necessary
to communicate effectively with physicians and others on the health care
team; competencies in care planning that integrate the biological, social, and
psychological needs of patients; understanding of and ability to seek and ap-
ply evidence-based protocols and national standards for patient conditions;
and payment and social services systems to better address the full range of
patients’ and families’ needs.
HEALTH POLICY EDUCATION
In large measure nursing education must remain patient focused. This makes
sense for an applied discipline whose goal is the prevention or amelioration of
illness and the improvement in the wellbeing of patients, families, and communi-
ties. However, a major lesson of the past 20 years is the degree to which health
systems and policy shape the health both of populations and individual patients.
Yet nursing students gain only a glimmer that health policy at multiple levels,
from the hospital unit to the federal government, affects not only their practice
but ultimately the fate of patients. Few educational programs include more than
a token course on health policy, typically only at the graduate level. Since nurs-
ing education curricula generally treat health policy as extra rather than core, the
naiveté of graduates, is no surprise. With few exceptions, nurses generally view
themselves as being shaped by, not shaping, policy.
Since nurses largely take a back seat to policy processes, the profession’s in-
put has been relatively invisible, certainly compared to that of medicine (Mechanic
and Reinhard, 2002). Few nurses, when asked “What is nursing?” include health
policy as a component of what nurses do (Gebbie et al., 2000). Missed opportu-
nities for nursing to shape legislation or wade into legislative debates are all too
common. One example is the recent Centers for Medicare and Medicaid Services
(CMS) rule that restricts reimbursement for such “never events” as pressure
ulcers, certain catheter-related infections and injuries, and certain surgical site

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infections. The majority of these conditions can be prevented by excellent nursing
care, yet the nursing profession has not effectively convinced the Congress or the
American public that nursing care is the key ingredient safeguarding the public
from these problems (Leavitt, 2009).
Another example is the “killing grandma” and “death panel” controversy,
sparked by wording in the August 2009 congressional health care reform bills.
Thousands of nurses across the country have daily, intimate contact with patients
and families in the throes of decision making about DNR orders, advance direc-
tives, and other end-of-life issues. Nurses have close personal knowledge about
how they and other clinicians facilitate discussions and considerations about palli-
ative care and life-extending treatments. Despite this, nurses were largely silent in
the face of widespread public misunderstanding and resulting acrimonious outcry
over what is intended in counseling patients facing such decisions. This silence is
surely an outgrowth of the inattention of nursing curricula to health policy.
The Healthy People Curriculum Task Force, convened by the Association of
Academic Health Centers and the Association of Teachers of Preventive Medi-
cine, with representatives from medicine, nursing, pharmacy, and physician as-
sistants, as well as their educational associations recommended the following
four domains fundamental to health professions curricula on health policy (http://
www.atpm.org/CPPH_Framework/index.html):
• Organization of clinical and public health systems (connecting the pieces
of the system; connecting clinical care to public health structures)
• Health services financing (underlying determinants of cost and options
for payment and cost containment; comparison to health systems of
other countries)
• Health workforce (understanding the roles and responsibilities of other
health professionals)
• Health policy process (introduction to the impact of policy on health
and clinical care, the processes involved in developing policies, and
opportunities to participate in those processes, whether within a local
institution or state or federal legislation)
Medicine has advocated the inclusion of these domains in all medical school
curricula (Riegelman, 2006). Nursing curricula should do no less.
As emphasized above, health policy curricula are needed at the baccalaure-
ate, master’s, and doctoral levels of nursing education, with increasing scope and
complexity as the student advances. Political competence requires continuing
skill development that begins early in students’ education, thus setting the course
toward the graduate’s life-long engagement.
Baccalaureate students need to understand the role of policies at the unit
level that shape the environment in which they will eventually work. Workplace
policies (e.g., mandatory overtime, nurses’ authority to close beds to new admis-

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APPENDIX I
sions based on professional judgment of adequate staffing, school nurses’ author-
ity to teach reproductive information) lend themselves for students’ analysis and
can help students clarify their own biases and potential ethical conflicts.
Another example of the type of policy work ideal for analysis by baccalau-
reate, and even graduate, nursing students pertains to the Robert Wood Johnson
Foundation and the Institute for Healthcare Improvement project, Transforming
Care at the Bedside (www.ihi.org/IHI/Programs/TransformingCareAtTheBed-
side/). TCAB is an excellent teaching–learning vehicle for students to gain un-
derstanding of local policy and how it is shaped. Originally designed as a way to
improve hospital work environments so that more nurses would seek (and stay)
in positions on medical–surgical units, TCAB also addresses care improvement
processes, such as rapid PDSA (plan-do-study-act) cycles for gathering data to
influence patient care policies. Faculty should engage baccalaureate students in
this TCAB literature, with application in clinical assignments and an emphasis
on policy implications and processes. In addition, baccalaureate students need an
understanding of the important role that nursing organizations can play so as to
encourage their involvement both as students and as graduates.
Graduate education in nursing, both at the master’s and doctoral levels,
should be infused with multiple learning experiences in health policy, including
both explication and hands-on experience. Building on the foundation from the
health policy curriculum at the baccalaureate level, APN students need to be ac-
tively involved in political processes that affect the care they will deliver in the
future. At this stage of their education, they should be expected to understand the
link between evidence and policy, i.e., the role that data can play in illuminating
problems and capturing the attention of policy makers. IPE can provide collab-
orative efficiencies so that interprofessional student groups engage together in
policy projects.
AACN’s DNP Essentials (www.aacn.nche/DNP/pdf/Essentials.pdf) includes
“Health Care Policy for Advocacy in Health Care” (Essential V), which expects
DNP graduates to engage in the health policy process, whether through institu-
tional decision-making, influencing organizational standards, or governmental
actions. It is expected that students will be oriented to the principles of social
justice, particularly in advocating for the underserved. Examples of hands-on
assignments include preparing and presenting a policy brief analyzing a state
or national health policy issue or problem related to access, utilization, cost, or
quality; writing a letter (not to be sent) to an editor or an elected official on a
health issue; and educating the lay public through speaking at local Rotary or
other civic organization.
At the PhD level, student understanding of how to impact health policy
moves specifically to the role of research. The focus at this level should be on
advanced knowledge of political processes within the state and federal govern-
ment and on the competencies needed to articulate research findings persuasively.
Students should understand how to plan their doctoral studies and related work,

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such as scholarly projects and the dissertation, toward the end goal of becom -
ing influential. Many authorities (e.g., McBride et al., 2008) urge researchers to
engage end users when framing research since those in position to make policy
frequently complain that the research they need is rarely available. A useful ex-
ercise for PhD students early in their program is to meet with a state or federal
elected member to discuss topics of mutual interest in improving health or health
care and determining what evidence may be useful in future policy agenda.
Linking research findings to health policy formulation requires a set of
specific skills which should be core to PhD education. These range from the con-
crete, for example, selecting a title for a policy brief or media report that reflects
the key take-away message (since busy policy makers will overlook material
that does not draw them in quickly), to the more conceptual, e.g., learning the
separate perspectives of legislators who make policy and researchers who study
health problems, which Hinshaw refers to as “moving between two cultures”
(Hinshaw, 2008).
Recommendations
1. In addition to health policy courses at baccalaureate, master’s, and doctoral
levels, health policy objectives should be threaded throughout the curricu-
lum, ideally embedded in every course and reflected in course assignments.
Using probing questions that invite student reflection, synthesis, integration,
and deduction, faculty should lead students to articulate the policy implica-
tions in everything they study.
2. Accreditation and licensure/certifying examinations must ramp up their ex -
pectations for student competencies related to health policy.
3. Health policy education should be structured around knowledge, skills and
competencies to include: policy-related relationship building skills; tech-
niques for crafting testimony and writing effective white papers and posi-
tion statements; effective use of numeric and narrative data to emphasize
evidence-based information; working with the media; critiquing the ethical
aspects of health policy in terms of vulnerable populations; mastering health
policy terminology; understanding legislators’ perspectives; techniques for
policy analysis; legislative processes in policy development; roles of stake-
holders and special interest groups; and advocacy and strategies to influence
policy.
EPILOGUE
The RWJF/IOM Initiative on the Future of Nursing will yield transforma-
tional recommendations for the nursing profession at a critical time in history for
nursing and for America’s health care system. There is much to reform in nursing
education, from agreement about the minimum degree for entry into practice to

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